Opioids for Chronic Pain: What You Need to Know

There is strong evidence that opioid therapy reduces the intensity of acute pain (pain present following tissue injury/trauma/surgery), cancer pain and pain for patients who are at end of life (palliative care).

However, there is little evidence to suggest that opioids have an effect in reducing chronic pain (pain that has been present for more than three months, and is termed as pain which continues after the tissues have healed).

Chronic pain cannot be measured just in terms of pain intensity, because chronic pain is also made up of physical, psychological, social, emotional and spiritual elements.

The goal of opioid therapy is to reduce (but not necessarily totally abolish) pain in order to improve function. Opioids are most effective if taken for no longer than 90 days after the onset of pain.

Commonly prescribed drugs which contain opioids are:

Tramadol

Codeine

Oxycodone

Targin

Palexia (tapentadol)

Endone

If you have been prescribed opioid therapy by your doctor or specialist for your pain, you should be monitored regularly so you don’t become at risk of remaining on long term opioid therapy, whereby the harm outweighs the benefits.

The 5 A’s of analgesia therapy you need to monitor are:

  1. Activity

Has opioid therapy helped you become more active despite your pain? Progress includes the ability to sit, stand, walk and perform daily activities more successfully.

  1. Analgesia

Is your opioid therapy effective in reducing your average pain as well as your worst pain?

  1. Adverse Effects

Have you experienced any adverse effects from the medication? These can include any of the following:

Constipation, respiratory depression, sleeplessness, sweating, palpitations, hypogonadism in males (reduced testosterone causing erectile dysfunction, infertility, decreased muscle mass, development of breast tissue, osteoporosis), sleep apnoea, falls, mental impairment, driving impairment.

  1. Aberrant Behaviours

Are you taking your opioid medication as prescribed?

When opioids are misused or abused, it does more harm than good. Examples include:

  • Missing work or school, neglecting family and friends, or endangering yourself.
  • Not being honest with your doctor, family and friends about your medication use.
  • Sharing or selling your medication.
  • Taking a higher dose than is prescribed.
  • Taking your medicine for reasons other than to relieve your pain.
  1. Affect

Have there been any changes in the way you feel? Is your pain impacting on your mood, or making you feel anxious or depressed?

What are you treating when taking opioids for your chronic pain?

If you have been taking opioids for longer than three months, despite them not reducing your pain levels or improving your function, it may be that you are using opioids to relieve your emotional suffering and distress.

Although addiction is rare, opioid tolerance is very common. This is where increased doses are given in the hope of reducing pain, but which may have the opposite effect, and actually cause an increase in pain, as well as an increased risk of harmful effects or even death.

What is considered problematic use of opioids?

Problematic use is defined as the use of high dose opioids (>100 mg per day) when there is continued significant pain and poor functioning. Often the only benefit of continued use is to relieve the symptoms of withdrawal, rather than to relieve the pain.

When an opioid drug is doing more ‘to you’ than ‘for you’, it is time to reconsider the therapy.

Common signs of opioid withdrawal include:

Anxiety

Insomnia

Muscle aches

Watery eyes and runny nose

Sweating

‘Goose bumps’

Yawning

Abdominal cramps and diarrhoea

Nausea

Dilated pupils

How can you manage your pain after you wean off opioids?

Chronic pain can cause a cycle of problems and worries which are difficult to change. Managing your chronic pain takes active commitment and may involve more health care professionals than just your GP.

Role of the GP:

Your doctor can discuss with you other non-opioid medications which might help your pain and also improve your ability to become more active. Medicines such as gabapentinoids, tricyclic antidepressants (TCAs), and serotonin-reuptake inhibitors (SNRIs) reduce pain, but don’t have the same harmful risks that high doses of opioids carry.

Role of the Physiotherapist /Exercise physiologist:

Your physiotherapist or exercise physiologist can help you understand your chronic pain and manage it better by:

  • Teaching you exercises that are enjoyable.
  • Teaching you how to set realistic and achievable daily goals.
  • Teaching you how to pace yourself.

This will also help reduce your pain and improve your confidence to be able to tackle meaningful activities which you may have been avoiding for fear of increasing your pain.

Dinah regularly runs an hour long  education session for patients in the Shearwater and Ulverstone clinics  about chronic pain, giving you a deeper understanding of why you have it and what influences in your daily life can contribute towards its intensity. Coping strategies taught include how to reduce your pain by setting realistic goals, correct pacing and managing flare ups effectively.

Call Shearwater or Ulverstone to book. Sessions cost the price of a standard physiotherapy  consult.

About the Author:

Dinah Spratt is a Physiotherapist at Physiotas in the North West.

Dinah has a special interest in the management of spinal and chronic pain conditions. She has worked in an advanced scope role for an orthopaedic spinal surgeon diagnosing and managing spinal patients conservatively and pre and post operatively. Dinah is currently studying a MSc in Medicine on Pain Management at Sydney University, which she will complete in 2018.

Dinah gives regular talks entitled ‘Chronic pain from a biopsychosocial perspective’ for patients, and is involved in presenting talks to GPs on this subject. She is based in the Physiotas Shearwater clinic.

References:

Backhouse, R, Goucke, R & Schug, S, Module 6, Opioids in Pain management, Better Pain Management, cited 8 May 2018, https://www.networks.anzca.edu.au/d2l/le/content/7381/viewContent/56883/View

Faculty of Pain Medicine, PM01, 2015 Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain, ANZCA, cited 8 May 2018, http://fpm.anzca.edu.au/documents/pm1-2010

Florida Health, When the prescription becomes the problem, Florida Health, viewed 8 May 2018.https//www.archive, epa,gov/region02/capp/web/pdf/ppcpflyer.pdf

Frei, M, Hunt, J, McCoy, D & Murnion, B, Module 11, High dose problematic opioid use, Better Pain Management, cited 8 May 2018, https://www.networks.anzca.edu.au/d2l/le/content/7381/viewContent/56883/View

Lifeline Australia https://www.lifeline.org.au/get-help/topics/substance-abuse-and-addiction

Mayo Clinic, Male hypogonadism, cited 8 May 2018, https://www.mayoclinic.org/diseases-conditions/male-hypogonadism/symptoms-causes/syc-20354881

O’Callaghan, J, Moore, B & Schug, S, Module 7, Pharmacology of pain medicine, Better Pain Management, cited 8 May 2018, https://www.networks.anzca.edu.au/d2l/le/content/7381/viewContent/56883/View

Pain Management Network 2014, 5 A’s- Opioid therapy monitoring tool, viewed 8 May 2018. https://www. Aci.health.nsw.gov.au/chronic-pain

Sullivan, M.D & Ballantyne, J.C 2012, ‘What are we treating with long-term opioid therapy?’, Arch Intern Med, vol. 172, no. 5, p. 433-434.